Failure to Ensure Timely Follow-Up Labs for Critical Sodium Levels
Penalty
Summary
The facility failed to ensure timely follow-up laboratory testing for a resident with a history of hyponatremia and other medical conditions following a critical lab result. The resident, who was moderately cognitively impaired and at risk for malnutrition, was discharged from the hospital with improved sodium levels but later had a critical serum sodium level of 99 identified in the facility. Although a provider ordered a Basic Metabolic Panel (BMP) to be drawn the following day, the order was canceled and replaced with a STAT order later that morning after it was discovered the initial lab had not been drawn. The STAT order was not entered into the lab portal until one hour and thirty minutes after being written, and the required notification to the lab service provider was not documented. The blood draw did not occur until late that evening, and the results again showed a critical sodium level. Interviews with facility staff revealed a lack of communication and understanding regarding the urgency and process for STAT lab orders, especially on non-routine lab days. The Director of Nursing acknowledged the facility's failure to process the initial BMP order, and the lab service provider confirmed that STAT orders required both entry into the portal and direct notification. The resident was ultimately found unarousable and transferred to the hospital with multiple critical diagnoses, including severe electrolyte imbalances and acute respiratory failure.